<style type="text/css">.input-group-addon{min-width:96px;}</style>
<form action="{$action_url}" method="POST">
	<input type="hidden" name="__token__" value="{$Request.token}" />
	<div class="input-group mt10">
			<span class="input-group-addon" id="basic-addon1">会&nbsp;员&nbsp;帐&nbsp;号&nbsp;</span>
			<input type="number" name="mobile" value="{$mobile}" class="form-control" placeholder="会员/手机号" aria-describedby="basic-addon1">
	</div>

	<div class="input-group mt10">
		<span class="input-group-addon"><label><input type="checkbox" id="blankCheckbox"  checked name="usepaycode">扣除余额</label></span>
		<input type="number" class="form-control" value="" placeholder="消费码">
	</div>

	<h5>设置次数</h5>

	<div class="input-group mt10">
		<span class="input-group-addon" id="basic-addon1">DIY乐园</span>
		<input type="number" id="give" name="give_money" class="form-control" placeholder="赠送金额" aria-describedby="basic-addon1">
	</div>
    <div class="input-group mt10">
		<span class="input-group-addon" id="basic-addon1">吃奶鱼</span>
		<input type="number" id="give" name="give_money" class="form-control" placeholder="赠送金额" aria-describedby="basic-addon1">
	</div>
	<div class="input-group mt10">
		<span class="input-group-addon" id="basic-addon1">动物滚球</span>
		<input type="number" id="give" name="give_money" class="form-control" placeholder="赠送金额" aria-describedby="basic-addon1">
	</div>

	<h5>选择时间范围</h5>

	<div class="row">
		<div class="col-sm-3 col-xs-6">
			<input type="date" id="birthday" class="form-control" name="birthday" value="{$today}">
		</div>
		<div class="col-sm-3 col-xs-6">
			<input type="date" id="birthday" class="form-control" name="birthday" value="{$one_month}">
		</div>
	</div>

	<div class="row">
		<div class="col-sm-4 col-xs-4">
			<button type="button" onclick="javascript:history.back(-1);" class="btn btn-default btn-lg btn-block mt10">上一页</button>
		</div>	
		<div class="col-sm-4 col-xs-4">
			<a href="{$detail_url}" class="btn btn-info btn-lg btn-block mt10">看详情</a>
		</div>
		<div class="col-sm-4 col-xs-4">
			<button onclick="formSubmit(this)" type="button" class="btn btn-primary btn-lg btn-block mt10">充值</button>
		</div>
	</div>
   
</form>
